Provider Demographics
NPI:1871983866
Name:CARTER, TINA D
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:D
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9245 WALLACE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7331
Mailing Address - Country:US
Mailing Address - Phone:318-581-0421
Mailing Address - Fax:
Practice Address - Street 1:7305 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:CAMPTI
Practice Address - State:LA
Practice Address - Zip Code:71411
Practice Address - Country:US
Practice Address - Phone:318-476-2205
Practice Address - Fax:318-476-2206
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7204089841041S0200X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool